CASE REPORT

ERYTHRODERMA CAUSED DRUG ALLERGIES

Asrawati Sofyan, Sitti Nur Rahmah, Asnawi Madjid
Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin
Sudirohusodo Hospital Makassar

ABSTRACT
Erythroderma is inflammation skin disease characterized by
erythema and scales almost or all over the body. Erythroderma is
Caused by many etiologies such as extended skin diseases, allergic
drug, systemic diseases and idiopathic. About 5-40% erythordermic
caused by allergic drug. Regardless of the underlying disease,
eryhtrodermic patient should be hospitalized. Erythroderma due to
allergic drug has a good prognosis, if the offending drug could be
established and withdrawn. We reported a case of erythroderma due to
drug eruption in a 56 year old woman. The management of this patient
include withdrawn the offending drugs, intravenous dexamethasone.
Topical corticosteroids as a dexosimethasone 0.025% ointment and
hydrocortisone 2.5% cream , have given a satisfying result.
Keywords: erythroderma, allergic drug, dexamethasone
hydrocortisone 2.5% cream, desoximethasone 0.25% ointment

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Erythroderma Caused Drug Allergies

INTRODUCTION

erythroderma showed the presence of T

helper-1 cytokines, whereas Sezary syndrome showed a T helper-2 cytokine by
different pathophysiological mechanisms.
(1)
Interleukin (IL) - 1, IL-2, IL-8 cellular
adhesion molecule (ICAM) - 1, tumor necrosis factor and interferon gamma is a
cytokine that plays a role in erythroderma.
Increased expression of adhesion molecules increased epidermal proliferation
and production of inflammatory mediators.

Erythroderma is a skin disorder

that belongs to a group papulosquamous
eruption, characterized by erythema and
squama which extends more than 90%
body surface area. (1-4) Another name for
this disease is exfoliative dermatitis, pityriasis rubra (Hebra), erythroderma ( WilsonBrocq), and erythema scarlatiniform. 1.5
Erythroderma can be caused by the
expansion of skin and systemic disease,
psoriasis 23%, spongiotic dermatitis 20%,
drug hypersensitivity reactions 15%, CTCL
(cutaneous T-cell lymphoma) or Sezary
syndrome 5% , seborrheic dermatitis
idiopathic 4%. (4)

(7)

Erythroderma
management
in
general is based on the etiology of
erythroderma itself. Hospitalization, where
dermatological care available, as well as
supporting facilities and adequate laboratory, generally can be a treatment option
for patients with erythroderma. Erythroderma can be a serious medical cases
and endanger the patient, and requires
hospitalization. (1,4,9) This case reported a
case erythroderma caused by drug eruption, in a woman, 56 years old. Patient
respond well to systemic and topical
corticosteroids.

The incidence of erythroderma

varied, ranging from 0.9 to 71 cases per
100,000 people. (1) From the data of a
study from 1981 to 2000, obtained results
which men are more often affected than
females with a ratio of 2.2: 1. ( 6) The
average age of patients with this disease
between 41-61 years old, in which children
are the exclusion criteria in this disease in
previous studies (1).

CASE REPORTS

The pathogenesis of the erythroderma is unclear. In general it can be said

that the pathophysiology of erythroderma
is almost the same regard-less of the
underlying disease. (4) In ery-throderma
turnover
increased
epidermal
cells
(epidermal turn over), so that the transit
time required keratinocytes through the
epidermis becomes shorter. Because
rapid succession, the stratum corneum,
there are a number of components that
are normally absorbed or metabolized. (7)
In addition, the increased circulation erythroderma epidermis and dermis, and vascular permeability. (8)

A woman, 56 years, came to

Bhayangkara Hospital Makassar, with
complaints of reddish spots on the entire
body experienced since 6 days ago.
Originally itching felt on both hands, 11
days ago, the patient went to Sungguminasa hospital and treated with cefadroxil, loratadine, and desoximethasone ointments. But there is no improve-ment,
itching and redness accompanied by
swelling widespread. Redness was originally found in mouth and face and then
the rest of the body. Fine scales showed
up all over the body and extremities later.
Patient complaint pain of eye and pain
during urination .Patient complained of
nausea. No fever. History of fever 2 days

The presence of cytokines in

dermal infiltration can vary depending on
the basis of erythroderma disease. Mild
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erythematous macular and fine scales.

And on face area is found erythematous,
squama and crusting.

before entering hospital and patient took

paracetamol. Based on history, pasient
had consumption of drugs / herbs before
itching and redness raised up. History of
drug allergies and food allergies were
denied. History of suffering with the same
complaint is denied. No previous skin
disease. A family history of similar complaints denied. History of diabetes and

From the results of laboratory tests

found a leukocytosis (28.700/l), and other
laboratory tests in normal. The results of
histopathological examination showed
psoriasiform hyperplasia epidermal, hyperkeratosis, parakeratosis, many neutrophil

accumulation in this area, focal hypogranulosis, spongiosis, papillary dermal blood

vessels dilate, containing erythrocytes.
Upper dermis contained dense infiltrates
of inflammatory lymphocytes, eosinophils,
neutrophils perivasculer. In conclusion :
chronic
spongiotic
dermatitis
drug
eruption.

hypertension is denied, the patient had a

history of suffering from sinusitis and polip
nasal. On physical examination found the
patient's general state of ill being, consciousness composmentis, sufficient nutrition. Vital signs within normal limits.
Dermatology examination on the entire
surface of the body (generalized) is found
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Asrawati Sofyan

Erythroderma Caused Drug Allergies

reduced. Because the lesions began to

improve, dexamethasone replaced with
oral medication methylprednisolone 20 mg
per day.

Patients diagnosed with erythroderma due to drug eruption, erythroderma

d ue to psoriasis vulgaris. Based on history, physical examination and histopathological examination, the diagnosis is
established erythrodermi ec drug eruptions. Treatment was given with cessation
of the suspected drugs, infusion of
Ringer's lactate (20 drops per minute),
intravenous injection dexamethasone 1
ampoule (5mg/ml) per 12 hours, ranitidine
1 ampoule per 12 hours, mebhidrolin
naphadisilate 50mg twice a day. Topical
treatment desoximethasone 0.025% ointment, and hydrocortisone 2.5% cream for
face area. Treatment for post-biopsy given
erythromycin 500 mg 3 times a day, and
sodium diclofenac tablet 3x1.

Seventh day of treatment, the

patient was allowed to go home, and
results dermatology examination showed
fine scales on the body, and only minimal
erythema in the region of vertebral and
recommended for visite an outpatient clinic
Bhayangkara hospital.
Patient was diagnosed erythroderma caused by drug allergies. Treatment
was continued methylprednisolone 20 mg
per day, mebhydrolin naphadisilat 2x 50
mg daily (if itchy) and topical treatment
desoximethasone ointment.

The second day of treatment

patient was consulted to the eyes doctor
with a diagnosed as dry eye and was
given cendo teen eye drops, patient was
also consulted to internist for chest pain.

DISCUSSION
From the history and physical
examination was found erythematous and
squama on almost the entire body, which
according to the existing literature on the
presence of symptoms of an erythematous
erythroderma and squama in the whole
body or most of the body. Erythroderma
classified into two, namely, primary
erythrodermic / idiopathic (20%) the cause

Fourth day of treatment, itching

was obtained, and erythema and squama
reduced, treatment was continued.
Sixth day of treatment, sometimes
itchy. Erythema and skin squama greatly
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Vol.1 No.4 2013

is unknown and secondary erythroderma

(80%) with a known cause, such as the
expansion of skin disease that has been
there before, medicines, basic disorders or
other systemic diseases . 1.410.

found were anemia, leukocytosis with

eosinophilia, erythrocyte sedimentation
rate (ESR) increased, hypoalbuminemia,
increased levels of uric acid. (13) In the
case of laboratory results showed leukocytosis (28.700/l).

In this case, erythroderma is

caused by an allergic reaction of medication. Prevalence of erythroderma induced
by different drugs in various populations.
In a study conducted by E. Euch D et al on
127 cases of erythroderma in Tunisia, 13
percent of the cause is obscure. Meanwhile, from the other literature mentioned
that the prevalence of drug-induced erythroderma is about 5 to 40 percent of all
cases of erythroderma. 10th

In this case, the results of histopathological examination a chronic spongiotic dermatitis because drug eruption.
In the literature it is said that a skin biopsy
of erytroderma due to drugs showed
parakeratosis, the disappearance of the
granular cell layer and
psoriasiform
hyperplasia. Histopathological examination
can not distinguish with certainty the
cause of erythroderma. Biopsy specimens
of erythroderma tend to exhibit nonspecific description such as hyperkeratosis, parakeratosis, acanthosis and chronic inflammatory infiltration. This discovery
is often covered histological of the underlying disease. One third of the biopsy
specimen failed to demonstrate basic
disease erythroderma diagnosis. Accurate
diagnosis of 50% established by dermatopathologist without obvious clinical information. Therefore, multiple biopsies recommended to increase the likelihood of a
histopathologic diagnosis. 1,4,14,15

There are many drugs that can

cause erythroderma. From various literature mentioned that drugs that often cause
erythroderma include calcium channel
blockers, antiepileptic, antimicrobial (cephalosporin, goals. Penicillin, sulfonamides,
vancomycin), allopurinol, gold, lithium, quinidine, cimetidine, NSAIDs and dapsone.
(1, 11.12).
Drugs most suspected as the
cause of erythroderma in these patients is
cefadroxil and did not rule out with an
unknown medication medicine names,
paracetamol and herbs. However, in order
to diagnose the type of drug suspects, one
of them to do patch test.

Differential diagnosis of erythroderma due to psoriasis removed because

based on history, the rash appeared after
patients taking the drug and no family who
suffered the same skin diseases . This is
contrast with psoriasis have a genetic
predisposition. (1) Erythrodermic psoriasis
begins with a typical psoriatic plaque on
the area of predilection of psoriasis. In the
clinical picture of this case showed fine
scale , in psoriasis scales are thick and
layered. (1.13)

Squama formed in erythroderma

varied, depending on the stage of
erythroderma and underlying disease. In
erythroderma due to an allergic reaction
drugs, squamas were found to be thinner.
(13)
In this case, initially redness of the lips
and face, and then spreads throughout the
body, within a few days. Redness of the
skin is also followed by the formation of a
thin squama.

Apart from various causes, erythroderma treatment should be performed in a

hospital. The principle of treatment is to

Laboratory findings in erythrodermic generally does not help to establish a

specific diagnosis. Abnormalities are often
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Erythroderma Caused Drug Allergies

keep the skin moist, avoid scratching,

avoiding trigger factors, providing topical
steroids, treat basic of disease, and deal
with complications that arise. That need to
be monitored are the nutrients, protein and
electrolyte balance, circulatory status, and
body temperature. (2.7)

argued that in this case of erythrodermic

patient had a good prognosis.
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